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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601018
Report Date: 05/17/2022
Date Signed: 05/17/2022 11:11:32 AM

Document Has Been Signed on 05/17/2022 11:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ABRAHAM REST HOMEFACILITY NUMBER:
075601018
ADMINISTRATOR:MARIA LORENZANAFACILITY TYPE:
740
ADDRESS:1148 FLOWERWOOD COURTTELEPHONE:
(925) 977-9743
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Annette SanchezTIME COMPLETED:
11:45 AM
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On 05/17/22 at 8:30AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with S1 upon entry, who then called the administrator who arrived at 9:50AM.

Facility has a mitigation plan in place dated 02/22/21 to mitigate the spread of COVID-19. LPA discussed the importance of having a completed mitigation plan (LIC 808) with administrator, as well as the infection control plan that she said will be complete in time for the 06/30/22 due date.

LPA inspected the facility inside and outside. LPA spoke with 4 of the 6 residents who all spoke very highly of the care they are receiving. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing.

A written Emergency/Disaster plan dated 05/16/22 was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were in locked cabinets adjacent to the kitchen. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were stored in a locked closet inside the garage. Infection control designated leader is the administrator.

Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ABRAHAM REST HOME
FACILITY NUMBER: 075601018
VISIT DATE: 05/17/2022
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Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged. All staff and 6 clients have been fully vaccinated.

Smoke and Carbon monoxide detectors were operational. Adequate supplies of PPE were also observed stored on the premises. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/24/22:

· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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